Damian McCormack

Birth-associated femoral fractures: Incidence and outcome

Femoral fractures resulting from birth injuries are rare. The authors undertook a study to assess their incidence and outcome. Seven patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births). Twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. A variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness. All patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up.

Anti‐biofilm activity of sub‐inhibitory povidone‐iodine concentrations against Staphylococcus epidermidis and Staphylococcus aureus

Biomaterial‐related infections continue to hamper the success of reconstructive and arthroplasty procedures in orthopaedic surgery. Staphylococci are the most common etiologic agents, with biofilm formation representing a major virulence factor. Biofilms increase bacterial resistance to antimicrobial agents and host immune responses. In staphylococci, production of polysaccharide intercellular adhesin (PIA) by the enzyme products of the icaADBC operon is the best understood mechanism of biofilm development, making the ica genes a potential target for biofilm inhibitors. In this study we report that the antibacterial agent povidone‐iodine (PI) also has anti‐biofilm activity against Staphylococcus epidermidis and Staphylococcus aureus at sub‐inhibitory concentrations (p < 0.001). Inhibition of biofilm by PI correlated with decreased transcription of the icaADBC operon, which in turn correlated with activation of the icaR transcriptional repressor in Staphylococcus epidermidis. These data reveal an additional therapeutic benefit of PI and suggest that studies to evaluate suitability of PI as biomaterial coating agent to reduce device‐related infections are merited.

Three-dimensional Motion Analysis of the Lumbar Spine during “Free Squat” Weight Lift Training

Background Heavy weight lifting using a squat bar is a commonly used athletic training exercise. Previous in vivo motion studies have concentrated on lifting of everyday objects and not on the vastly increased loads that athletes subject themselves to when performing this exercise. Hypothesis Athletes significantly alter their lumbar spinal motion when performing squat lifting at heavy weights. Study Design Controlled laboratory study. Methods Forty-eight athletes (28 men, 20 women) performed 6 lifts at 40% maximum, 4 lifts at 60% maximum, and 2 lifts at 80% maximum. The Zebris 3D motion analysis system was used to measure lumbar spine motion. Exercise was performed as a “free” squat and repeated with a weight lifting support belt. Data obtained were analyzed using SAS. Results A significant decrease (P < .05) was seen in flexion in all groups studied when lifting at 40% maximum compared with lifting at 60% and 80% of maximum lift. Flexion from calibrated 0 point ranged from 24.7° (40% group) to 6.8° (80% group). A significant increase (P < .05) was seen in extension when lifting at 40% maximum was compared with lifting at 60% and 80% maximum lift. Extension from calibrated 0 point ranged from —1.5° (40% group) to —20.3° (80% group). No statistically significant difference was found between motion seen when exercise was performed as a free squat or when lifting using a support belt in any of the groups studied. Conclusion Weight lifting using a squat bar causes athletes to significantly hyperextend their lumbar spines at heavier weights. The use of a weight lifting support belt does not significantly alter spinal motion during lifting.

Paediatric pelvic ring fractures and associated injuries.

INTRODUCTION Paediatric pelvic fractures have been infrequently reviewed. The study was performed to highlight the unique features of pelvic fractures in children. PATIENTS AND METHODS A 14-year retrospective study was undertaken of all patients treated for a pelvic fracture at our institute. RESULTS Thirty-nine children were included. The mean Injury Severity Score (ISS) was 17.1 (range 4-75). Simple ring fractures were the most common type (46%), dominated by pedestrian versus motor vehicle trauma (58.9%). A pelvic fracture was evident on the initial plain radiographs of all 39 children. Further radiographic investigations (12 CTs and 1 MRI) were undertaken in 13 (33%) of the children. Additional posterior ring fractures were identified in 9. A total of 32 children (82%) sustained one or more associated injuries. Head injuries accounted for 25% and orthopaedic/skeletal injuries for 33% of all associated injuries. Fourteen children required a total of 24 acute surgical procedures. Mean out-pateint clinical follow-up was for 27 months (range 3-85). There was one mortality in this series. Eight children (20%) suffered long term sequale. CONCLUSION Paediatric pelvic fractures differ from their adult counterpart in aetiology, fracture type, and associated injury pattern. They represent a reliable marker for severe trauma. Prospective studies are required to define optimal treatment guidelines, particularly in older children.

Hydrogen Peroxide Induced Repression of icaADBC Transcription and Biofilm Development in Staphylococcus epidermidis

Expression of the icaADBC‐encoded polysaccharide intercellular adhesion by Staphylococcus epidermidis promotes biofilm formation and represents an important virulence factor in biomaterial‐related infections following orthopedic surgery. Biofilm development by the pathogen can be viewed as a protective reaction to environmental stressors including osmotic stress, thermal stress, and antimicrobial chemotherapy. Oxidative stress, arising from the release of toxic oxygen radicals by polymorphonuclear cells, is encountered by bacteria entering the body perioperatively. Evasion of this and other cell‐mediated immune responses by pathogenic bacteria plays an important role in the development of chronic biomaterial‐related infection. Here we investigated the impact of sublethal oxidative stress induced by H2O2 (<18 mM) on S. epidermidis biofilm formation. S. epidermidis grown in brain heart infusion (BHI) media supplemented with 5 mM H2O2 or 10 mM H2O2 formed significantly less biofilm (p < 0.01 and p < 0.001, respectively) than bacteria grown in BHI alone. Consistent with this, using reverse transcription‐polymerase chain reaction expression of the ica locus was also shown to be reduced by subinhibitory concentrations of H2O2. Furthermore, diminished ica operon expression correlated with increased expression of icaR, which encodes a repressor of icaADBC. Thus, these data suggest that mild oxidative stress downregulates biofilm development by S. epidermidis and may have potential in a therapeutic context.

Heelys and street gliders injuries: a new type of pediatric injury

OBJECTIVES. Our goals were to highlight an increasing trend in orthopedic injuries in children as a result of “heeling” or “street gliding,” to describe injuries sustained by children using Heelys (HSL, Carrollton, TX) and Street Gliders (Glowgadgets Ltd, Bristol, United Kingdom), and to increase public awareness and prevent such injuries. PATIENTS AND METHODS. We prospectively recorded the data of all roller shoes injuries referred to our department during the summer school holiday. Using a data-collection sheet, we recorded demographic data, type of injury, mechanism and place of injury, heeling or street-gliding experience, use of safety equipment, methods of treatment, and intention to continue heeling or street gliding after recovery from injury. RESULTS. Over a 10-week period, 67 children suffered orthopedic injuries while using Heelys or Street Gliders. There were 56 girls and 11 boys with a mean age of 9.6 years. Upper limbs were the most common location of injury. Distal radius fractures were the most prevalent, followed by supracondylar fractures, elbow dislocations, and hand fractures. The majority of children suffered the injury while heeling or street gliding outdoors. Interestingly, 20% of the injuries happened while trying Heelys or Street Gliders for the first time, and 36% of the injuries occurred while learning (using 1–5 times) how to use them. None of the children used any sort of protective gear at the time of the injury. The majority of the injured children expressed their intention to continue heeling or street gliding after complete recovery from their injury. CONCLUSIONS. Our study shows that the majority of children with injuries from heeling or street gliding are girls. We recommend close supervision of children using Heelys or Street Gliders during the steep learning curve and usage of protective gear at all times. These new types of injuries have a serious impact on child health and constitute a burden for the pediatric orthopedic service.

Sternoplasty and rib distraction in neonatal Jeune syndrome.

Background A 12-week-old boy with Jeune syndrome (asphyxiating thoracic dystrophy) was referred to the orthopaedic unit with progressive respiratory failure, recurrent respiratory tract infections, and recurrent admissions to the intensive care unit for ventilatory support. His chest x-ray revealed a small and narrow thoracic cage with short broad ribs and abnormal costal cartilages. His chest expansion was impaired by the short, horizontally positioned ribs resulting in alveolar hypoventilation. Without surgical intervention to expand his thoracic cage, he would die of respiratory failure. Methods Using the technique of distraction osteogenesis, we split his sternum and slowly expanded this split to a total of 3 cm using a Leibinger mid-face distractor allowing adequate wound healing and bone formation between the 2 sternal edges. He returned to the theater 4 weeks after his initial surgery to have the distractor removed and 2 Leibinger plates inserted to hold the sternum out to length. Sternal distraction was repeated and the sternum was then supplemented with a Leibinger mesh. At 8 months, he had successful expansion of his ribs bilaterally using this technique of distraction osteogenesis. Results Presently, the patient is 30 months old and is living at home, is not oxygen dependent, and continues to thrive. Conclusions Jeune syndrome presenting with respiratory failure in the neonate is fatal without surgical intervention to expand the thoracic cage. No successful surgical techniques have been described in the literature for neonates. This is the first case in which distraction osteogenesis has been used to distract both sternum and ribs in an infant with Jeune syndrome. Hence, distraction osteogenesis in thoracic dystrophy is a novel approach in the neonate. Level of Evidence Case report.

A comparison of pediatric forearm fracture reduction between conscious sedation and general anesthesia.

Objectives: The purpose of this study was to compare the outcomes of children whose fractures were manipulated with nitrous oxide with those fractures manipulated under a general anesthetic. Design: We undertook a retrospective analysis of all children who presented to the emergency department with an angulated or displaced nonphyseal forearm fracture requiring manipulation over a 6-month period. Patients/Participants: Twenty-eight forearm fractures were manipulated using conscious sedation, whereas 27 were manipulated in the operating theatre under general anesthesia. Main Outcome Measurements: The quality of reduction, the Cast Index, Padding Index, and Canterbury Index were similar between the 2 groups. Results: There was a significant difference between the need for remanipulation in the nitrous oxide group (9) compared with the need for remanipulation in the theatre group (3). Conclusions: Despite a higher failure, manipulation of fractures in the emergency department using conscious sedation can achieve an adequate reduction and a high quality of cast. Failures were due to inherently more unstable fracture personalities. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Less invasive innominate osteotomy.

In 1961, Salter described the innominate osteotomy for the treatment of dysplastic acetabulum in children presenting late with developmental dysplasia of the hip. He recommended the Gigli saw as the safest instrument for the osteotomy cut and his postoperative immobilization was with a hip spica cast. These have been the standard practice. However, an extensive exposure is required to facilitate passage of the Gigli saw under the sciatic notch while the application of a hip spica can be difficult and prolongs anaesthetic time. We describe a less invasive technique using an oscillating saw for the osteotomy cut. This allows for minimal exposure hence short operation time and quick recovery. We use an abduction brace for our postoperative immobilization thereby significantly reducing anaesthetic time. Fifty innominate osteotomies performed in 49 patients using this technique were reviewed retrospectively. There were 46 female and three male patients. The senior author performed all surgeries. The average age at surgery was 24 months (18–54) and the mean follow-up period was 25 months (12–60). The mean preoperative acetabular index was 35.1°, whereas the acetabular index at final follow-up was 14.9° (P<0.0001). Average duration of surgery was 25 min with minimal blood loss (less than 50 ml). All went home by the second postoperative day. There was no intraoperative complication. Two patients had minor superficial wound infections that resolved uneventfully. There was no loss of correction. We suggest that the oscillating saw is a safe instrument for performing an innominate osteotomy, it allows for less invasive surgery hence less morbidity and quicker recovery without compromising the surgical outcome. The abduction brace can be used for immobilization after innominate osteotomy without loss of correction.

Use of a cementless modular implant for arthroplasty in developmental dysplasia of the hip: Early results

Total hip arthroplasty for osteoarthritis secondary to developmental dysplasia of the hip (DDH) is technically difficult due to the abnormal anatomy involved. Surgery may be facilitated by using a modular femoral prosthesis, which allows intra-operative variations in neck length and version to accommodate final acetabular position. The aim of this study was to assess our early results with the S-ROM hip (DePuy), a cementless modular femoral implant, for arthroplasty in patients with DDH. We performed 22 total hip replacements on 20 patients over a three and a half year period. Ten patients had had previous osteotomies performed, including two of whom had Ganz peri-acetabular osteotomies performed in our centre. Follow-up ranged from 6 to 44 (mean 19.6) months. Harris hip scores improved from an average of 42 points pre-operatively to 90 points post-operatively. No radiographic evidence of osteolysis was seen around the femoral implant. Two patients required revision of their acetabular components. Both had satisfactory outcomes. Our early results with the S-ROM femoral prosthesis correlate well with those from other studies involving arthroplasty for DDH. This implant is extremely versatile and easy to use in this complex patient population.RésuméL’arthroplastie totale de hanche pour coxarthrose secondaire à une dysplasie constitue une difficulté technique en raison des modifications anatomiques. La chirurgie peut être facilitée en utilisant une prothèse fémorale modulaire, qui autorise des variations per-opératoires de longueur, d’excentration et d’antéversion du col afin de s’adapter à la position acétabulaire finale. Le but de cette étude était d’évaluer nos premiers résultats avec la hanche S-ROM (DePuy, Johnson et Johnson Company), un implant fémoral modulaire non cimenté dédié aux patients porteurs de dysplasie. Nous avons réalisé vingt deux remplacements totaux de hanche chez 20 patients, étalés sur une période de trois ans et demi. Dix patients avaient été opérés auparavant par ostéotomies, y compris deux par ostéotomies peri-acétabulaires de Ganz exécutées dans notre Centre. Le follow-up s’est étendu de six à 44 mois (moyenne 19.6 mois). Le score de hanche de Harris a été amélioré en passant, en moyenne, de 42 points en pré-opératoire à 90 points en post-opératoire. Aucun signe radiographique d’ostéolyse n’a été constaté autour de l’implant fémoral. Deux patients ont nécessité une révision de leurs composants acétabulaires. Tous les deux ont eu des résultats satisfaisants. Nos premiers résultats avec la prothèse S-ROM fémorale se corrèlent bien avec ceux d’autres études d’arthroplasties pour hanches dysplasiques. L’auteur aîné trouve cet implant extrêmement souple, et facile à employer dans cette population patiente complexe.